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What do surveyors want to see in your EC plans?

Accreditation Connection, June 4, 2004

Complying with the JCAHO's 2004 Environment of Care (EC) standards means more than conducting regular fire drills and making sure your backup generators are working properly.

Surveyors will likely delve into EC issues as part of the new patient-tracer process, potentially asking staff about the last service date for medical equipment, or whether refrigerators for blood products are connected to emergency generators.

When reviewing EC policies and procedures, you need written management plans for each of the seven sections, says Kenneth Weinberg, PhD, president of Safdoc Systems, LLC, in Stoughton, MA. The seven EC sections are safety, security, hazardous materials and waste, emergency management, fire safety, medical-equipment management, and utilities.

During an on-site visit, surveyors will review your management plans to gain a sense of how you address EC standards, how you correct problems, and how you maintain the quality of your facility. All the plans should be in a consistent format, says Weinberg. The management plans should identify the following information:

Who is responsible for overseeing this section

When the responsible party will review the section for scope and effectiveness

Who gets copies of the maintenance and performance-improvement reports

How staff will carry out requirements for improvement

Click here to read more about the JCAHO's 2004 EC standards.

Editor's note: We adapted this story from the recent HCPro audioconference, "JCAHO's 2004 Environment of Care Standards: How to comply with JCAHO's seven safety management plans." Go to www.hcmarketplace.com/Prod.cfm?id=1481 to order a copy of the tape.

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